Warfarin Use and the Risk for Stroke and Bleeding in Patients With Atrial Fibrillation Undergoing Dialysis

Abstract

Editorial see p 1190 Clinical Perspective on p 1203CKD is also considered as an independent risk factor for bleeding, and, therefore, warfarin use in patients who have severe CKD could increase the risk for bleeding. 2 Moreover, in patients with AF undergoing hemodialysis, it is routine practice to administer heparin, which could also increase the risk for bleeding. 15Current observational studies on warfarin use and the risk for stroke and bleeding in patients with AF undergoing dialysis present conflicting results. 1,8,16,17 Globally, because of a lack of evidence from randomized, controlled trials, AF Background-Current observational studies on warfarin use and the risk for stroke and bleeding in patients with atrial fibrillation (AF) undergoing dialysis found conflicting results. Methods and Results-We conducted a population-based retrospective cohort study of patients aged ≥65 years admitted to a hospital with a primary or secondary diagnosis of AF, in Quebec and Ontario, Canada from 1998 to 2007. The AF cohort was grouped into dialysis (hemodialysis and peritoneal dialysis) and nondialysis patients and into warfarin and no-warfarin users according to the first prescription filled for warfarin within 30 days after AF hospital discharge. We determined the association between warfarin use and the risk for stroke and bleeding in dialysis and nondialysis patients. The cohort comprised 1626 dialysis patients and 204 210 nondialysis patients. Among dialysis patients, 46% (756/1626) patients were prescribed warfarin. Among dialysis patients, warfarin users had more congestive heart failure and diabetes mellitus, but fewer prior bleeding events in comparison with the no-warfarin users. Among dialysis patients, warfarin use, in comparison with no-warfarin use, was not associated with a lower risk for stroke (adjusted hazard ratio, 1.14; 95% confidence interval, 0.78-1.67) but was associated with a 44% higher risk for bleeding (adjusted hazard ratio, 1.44; 95% confidence interval, 1.13-1.85) after adjusting for potential confounders. Propensity score-adjusted analyses yielded similar results. Conclusions-Our results suggest that warfarin use is not beneficial in reducing stroke risk, but it is associated with a higher bleeding risk in patients with AF undergoing dialysis.

Pharmacotherapy for Atrial Fibrillation in Patients With Chronic Kidney Disease: Insights From ORBIT‐AF

“…Three analyses identified an association between warfarin use and increased risk for bleeding and embolic stroke,11, 12, 13 while the fourth analysis associated warfarin use with an increased risk of bleeding and a decreased risk of stroke or systemic embolism 14. In the present analysis, a trend towards increased bleeding as well as all‐cause stroke, systemic embolism, or TIA was observed in patients with Stage IV or V CKD treated with an OAC compared with patients without CKD that received an OAC.…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…Nie przeprowadzono żadnych randomizowanych prób klinicznych, w których oceniono by OAC u pacjentów leczonych hemodializami [418] ani kontrolowanych prób klinicznych stosowania NOAC u pacjentów z ciężką CKD (CrCl < 25-30 ml/min) [318][319][320][321]. Stosowanie warfaryny wiązało się z neutralnym lub zwiększonym ryzykiem udaru mózgu w analizach baz danych obejmujących pacjentów dializowanych [419][420][421], w tym w analizie populacyjnej przeprowadzonej w Kanadzie (skorygowany HR udaru mózgu 1,14; 95% CI 0,78-1,67; skorygowany HR krwawienia 1,44; 95% CI 1,13-1,85) [422]. Natomiast dane z Danii wskazują na korzyści z OAC u pacjentów poddawanych leczeniu nerkozastępczemu [423].…”

2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS

“…318 -321 Warfarin use was associated either with a neutral or increased risk of stroke in database analyses of patients on dialysis, 419 -421 including a population-based analysis in Canada (adjusted HR for stroke 1.14; 95% CI 0.78 -1.67, adjusted HR for bleeding 1.44; 95% CI 1.13 -1.85). 422 In contrast, data from Denmark suggest a benefit of OAC in patients on renal replacement therapy. 423 Hence, controlled studies of anticoagulants (both VKAs and NOACs) in AF patients on dialysis are needed.…”